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Dr. Sharmila Glaucoma clinic

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Presentation on theme: "Dr. Sharmila Glaucoma clinic"— Presentation transcript:

1 Dr. Sharmila Glaucoma clinic
Basics in Glaucoma Dr. Sharmila Glaucoma clinic

2 Glaucoma Glaucoma is an optic neuropathy with characteristic appearance of the optic disc and specific pattern of visual field defects that is associated frequently but not invariably with raised IOP



5 POAG Adult onset IOP > 21mm Hg Open Angles
Glaucomatous nerve damage Visual field loss

6 Risk factors Age > 65 Black race Positive family history Myopia Thin Corneas

7 Pathogenesis Increased resistance to aqueous outflow Ischaemic Theory
Mechanical theory

8 pathogenesis Pathogenesis

9 Symptoms Usually asymtomatic Rarely decreased visual fields

10 Diagnosis of glaucoma History taking
Visual acuity and refractive state Tonometry Gonioscopy Ophthalmoscopy Perimetry

11 Tonometry Indentation tonometry-schiotz tonometer
Applanation tonometry variable force-goldmann Tonopen variable area- maklakov Non contact tonometer

12 Schiotz indentation Tonometry
Body –footplate-rests on the cornea Plunger Weights- 5.5gm –permanently fixed. additional weights-7.5g.10g,15g

13 Technique of schiotz tonometry
Anaesthetise cornea Patient in supine position Fixes on the target Eyelids gently separated Plunger rests on cornea. Look for movement of the needle Additional weights –if reading is <4 IOP derived from conversion table

14 Sources of error Ocular rigidity
High ocular rigidity-high hyperopia,long standing glaucoma,ARMD Low ocular rigidity –high myopia,osteogenesis imperfecta,miotic therapy,retinal surgeries Thick cornea-high value



17 Gonioscopy Goniolens[direct] Koeppe, layden, barken Gonioprism
Goldman single mirror, two mirror, three mirror Zeiss four mirror Posner four mirror

18 Normal angle structures
Ciliary body band Scleral spur Trabecular meshwork Schwalbe’s line

19 Ophthalmoscopy Disc Focal atropy Concentric atrophy
Deepening of the cup Advanced glaucomatous cupping Vascular changes Haemorrhage,baring of vessels, bayonetting Retinal nerve fiber layer changes Peripapillary atrophy


21 Perimetry Kinetic Static Visual fied defects Paracentral scotoma
Seidel scotoma Arcuate scotoma Double arcuate scotoma Nasal step

22 Angle Closure Glaucoma
With pupillary block Without pupillary block Diagnosis depends on : Anterior segment examination Gonioscopy

23 Risk factors Age Gender Asians, Chinese, Eskimos Family history

24 Pathogenesis Increased opposition between iris and lens enhance the degree of pupillary block Increased pressure in posterior chamber Increased peripheral iris bowing Iris Bombe High IOP

25 Types Latent Subacute Acute congestive Post congestive Chronic

26 Acute Congestive Glaucoma
Symptoms Severe pain and vomiting Unilateral visual loss coloured haloes Headache and vomiting

27 Signs Shallow AC Corneal edema Semi dilated pupil High IOP
Closed angles

28 Treatment Immediately 2% Pilocarpine Steroid eye drops Β blockers
Analgesics and antiemetics Lie in supine position I.V. Mannitol + Oral T. Diamox


30 Cont.d… After 1 hr: After 11/2 hr: Pilocarpine 2% Yag PI
If IOP is still high 50% oral glycerol 20% Mannitol (1-2g/kg) I.V. over 45minutes

31 Laser Iridotomy Clear corneas Less than 1800 of angle by PAS
Surgery: Trabeculectomy

32 Congenital Glaucoma 1:10,000 births 65% are boys Pathogenesis:
Maldevelopment of the angle of anterior chamber

33 Classification Congenital Glaucoma Infantile Glaucoma
Juvenile Glaucoma

34 Clinical Features Corneal edema Buphthalmos Breaks in DM
Optic disc cupping

35 Diagnosis Increased IOP Increased Corneal diameter > 11mm at 1yr
Treatment: Goniotomy Trabeculotomy trabeculectomy

36 Lens related Glaucomas
Phacolytic: Hyper mature cataract Corneal edema AC reaction – psuedo hypopyon Open angles

37 Treatment Anti glaucoma drugs Topical antibiotic steroids surgery

38 Phacomorphic Galucoma
Intumscent cataractous lens Shallow anterior chamber Treatment: Antiglaucoma drugs Laser iridotomy surgery

39 Neo vascular Glaucoma Retinal ischaemia NVI NVA OPEN ANGLE

40 Causes Ischeamic CRVO Diabetes Mellitus Miscellaneous Carotid disease
Intra ocular tumor Long standing RD

41 Symptoms & Signs Decreased visual acuity Congestion of Globe
Very high IOP and corneal edema Severe pain Aqueous flare NVI Gonioscopy - NVA

42 Treatment Medical – topical Atropine & steroids
Retinal ablation / - DIODE CPC Surgery: Trab with MMC Aqueous drainage shunts Retrobulbar alcohol injection Enucleation

43 Treatment Modalities in glaucoma
Medical Laser Surgery – Trabeculectomy combined surgery

44 Anti Glaucoma Drugs Β blockers Contra indications:
Decreases IOP by decreasing aqueous secretion Contra indications: Congestive cardiac failure Heart block Bradycardia Bronchial asthma

45 Side effects Iotim, Nyolol, Glucomol 0.5% bd Ocular Systemic
allergy Bradycardia, Hypotention SPK’s Broncho spasm tear secretion Hallucination, head ache nausea, dizziness

46 Alpha 2 Agonists Mechanism: Side Effects: Brimonidine, apraclonidine
Decreases aqueous secretion Increases uveo scleral outflow Side Effects: Allergic conjunctiviti s Xerostomia Drowsiness and headache

Mechanism Decreases IOP by increasing uveoscleral outflow Latanoprost F2 α analogue.005% Travoprost 0.004% Bimatorpost 0.3% Unoprostone 0.15% BD

48 Side Effects Conjunctival hypereamia
Eye lash growth and hyperpigmentation of periorbital skin Anterior uveitis Cystoid macular edema

49 MIOTICS Pilocarpine 1% 2% 3% 4% QID
Parasympathomimetic stimulates muscarinic receptors in sphincter pupillae & ciliary body In POAG – increases aqueous outflow In PACG – opens the angles

50 Side Effects Miosis Browache Myopic shift Visual field defect

51 Carbonic Anhydrase Inhibitors
Inhibits aqueous secretion Topical CAI Dorzolamide (Trusopt) Brinzolamide (Azopt) Systemic CAI Acetazolamide 250mg BD

52 Side Effect Parasthesia Malaise GI upset Renal Stone Blood dyscrasias

53 Hyper Osmotic Agents Glycerol 1g / kg in 50% solution
Mannitol 1-2g/kg in 20% solution Side Effects: Cardiac or renal failure Urinary retention Head ache, nausea

54 Lasers in Glaucoma Laser Iridotomy: Indications: PACG
Occludable angles SACG with pupillary block Combined mechanism glaucoma

55 Laser PI prerequisites Instil 1% Apraclonidine Miotic pupil
Laser settings 4-8 mJ Post laser steroid eye drops Abraham lens

56 Complications Bleeding Iritis Corneal burn Glare Diplopia

57 Surgery Trabeculectomy:
A conventional filtering procedure creates a new channel for aqueous outflow between the anterior chamber and subtenons space without the use of an artificial device Partial thickness Full thickness

58 Management of coexistent cataract and glaucoma

59 Complications Wound leak Excessive filteration Pupillary block Malignant glaucoma Hypotony Choroidal detachment

60 Failing bleb Initial few weeks critical SIGNS Injection
Vascularisation Thickening Localization High domed Bleb Normal / High IOP Low IOP Initial few weeks critical

61 Failing filtration Frame work for Classification IOP Bleb

62 Failing filter – High IOP
Low localized Bleb External Subconjunctival fibrosis - Tight scleral flap sutures Internal - Sclerectomy obstruction

63 Failing filter – High IOP
High domed bleb – encapsulated bleb or Tenon’s cyst

64 Failing filter - Low IOP
Elevated diffuse bleb - Over Filtration hypotony Low bleb - Bleb leak

65 Bleb Failure Argon laser suturolysis 0.2sec 50µ 500-700mw
Digital massage Topical steroids 5FU injection DF Nd yag laser Needling of tenons cyst


67 Refractory glaucomas Cyclo destructive procedures

68 New diagnostic and surgical procedures
Central corneal thickness assessment



71 Thank you



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